OBJECTIVE:
To analyze the association between alcohol advertising and beer drinking among
adolescents.METHODS: A total of 1,115 students enrolled in the 7th and 8th grades
of three public schools in São Bernardo do Campo, Southeastern Brazil,
were interviewed in 2006. The independent variables were as follows: attention
paid to alcohol advertisements, belief in the veracity of advertisements, affective
response to advertisements and previous tobacco use, among others. The dependent
variable was beer drinking in the last 30 days. Univariate and multiple logistic
regression analyses were made. Age, importance given to religion and the presence
of a bathroom in the home were used as control.RESULTS: Beer drinking in the last 30 days was associated with tobacco
use (OR = 4.551), having a favorite alcoholic beverage brand (OR = 5.150), poor
parental supervision (OR = 2.139), considering parties one goes to as similar
to those seen in commercials (OR = 1.712), paying more attention to advertisements
(OR = 1.563) and believing that advertisements tell the truth (OR = 2.122).
This association remained, even in the presence of other variables associated
with beer drinking.CONCLUSIONS: Alcohol advertisements are positively associated with recent
beer drinking, because they remind adolescents of their own reality or make
them believe in their veracity. Alcohol advertisement restrictions can be one
way to prevent alcohol use and abuse by adolescents.

The onset of alcohol
use is influenced by individual and interpersonal factors, including family,
biological, behavioral and environmental aspects,12,15,16,19 among
which alcohol advertising is found.2,12,19,20,21,26

Studies indicate
that advertising influences alcohol drinking among adolescents.6,16,19,a
Although extensive research on alcohol advertising has not been conducted in
Brazil, this debate began in the world more than 20 years ago.1 There
are two main types of studies on this theme: econometric ones and consumers'
ones.

Econometric studies
usually analyze spending on advertisements (used to evaluate exposure and response)
and total consumption (used to evaluate alcohol-related harms). Spending on
advertisements was also compared to problems associated with alcohol beverages,
such as motor vehicle accidents and clinical problems resulting from chronic
alcohol use.1,ª Snyder et al26 showed
that American adolescents living in areas with higher spending on advertisements
drink greater amounts of alcoholic beverages, including those aged more than
20 years. Nonetheless, econometric studies have flaws, such as the lack of distinction
between adults and adolescents.18

Consumers' studies
are those that "use an individual as a unit of analysis",1 i.e.,
they analyze and predict adolescents' responses to alcohol advertisements. Analyses
are based on exposure to advertisements, affective response and influence on
adolescents' expectations towards alcoholic beverages.3,12,13,16,26

Certain authors,
such as Austin & Mieli,5 Ellickson et al,12 Collins
et al,10,11 Grube & Waiters18 and Fleming et al,16
explore the responses of those exposed to advertisements as predictors of current
and future alcohol use. Other authors, such as Stacy et al26 and
Snyder et al,25 analyze exposure with a quantitative approach, based
on the assumed hours of exposure.

Studies on this
theme that have been published were conducted in developed countries, whose
alcoholic beverage markets are relatively stable. Brazil is a market with great
potential for growth, due to its growing economy and large population (with
a high proportion of adolescents).b The majority
of Brazilian adolescents do not drink alcoholic beverages regularly,24,c and the habits and living conditions of the population of Brazil are
different from those of the countries studied. Original studies must be conducted
in the Brazilian culture to evaluate the possibility of comparing this reality
with data from other locations.

In Brazil, there
are not many restrictions to alcohol advertising, apart from the few alcohol
prevention programs existing. This country adopted the self-regulatory model
of the Conselho de Auto-Regulamentação Publicitária (CONAR
- Self-regulatory Marketing Council),d
and the rules are mainly related to content and exposure of minors to such advertisements.
Considering the efficacy of this questionable self-regulation,15
the Brazilian government attempted to restrict beer advertisements on television
in 2008, through the Agência Nacional de Vigilância Sanitária
(ANVISA - National Health Surveillance Agency) and the Ministry of Health. However,
movements led by beer companies and associations representative of means of
communication managed to revert these proposals, so that there is currently
no time restriction to advertisements of these beverages.

This article aimed
to analyze the association between alcohol advertising and beer drinking among
adolescents.

METHODS

This study is part
of a longitudinal study conducted with 1,132 students enrolled in the 7th
and 8th grades of three public schools situated near downtown São
Bernardo do Campo, Southeastern Brazil, between 2006 and 2007. São Bernardo
do Campo has approximately 660,400 inhabitants, with demographic characteristics
similar to those of the majority of urban centers in Brazil, in terms of age,
household income and level of education (IBGE 2000).b
Inside the public school system, the socioeconomic pattern of students is homogeneous.

The schools selected
included 34 seventh and eighth grade classes, with 33 students per class on
average. The choice for interviewing students in these grades resulted from
the 2004 National Survey of the Centro Brasileiro de Informações
sobre Drogas Psicotrópicas (CEBRID - Brazilian Center of Psychotropic
Drug Information),c according to which the beginning
of alcohol drinking in Brazil occurs at the mean age of 12.5 years.

Students previously
received an informative pamphlet on the study with the coordinator's contact,
so that adults responsible for these students could consent to their participation
or not. There were no refusals and all students present on the application day
were interviewed using confidential questionnaires, which were completed these
students themselves. Interviews were conducted in two periods: between August
and November 2006 and between August and November 2007. This article refers
to the results of the first period.

The questionnaire
was about aspects such as parental monitoring,17 previous tobacco
use, and the importance of religion in one's life, among other things. The instrument
was mostly based on the questionnaire developed by Collins et al (2005),11
in addition to Stacy et al (2004)26 and Austin et al (1994).3
A total of three focus groups were conducted with public and private school
students to guarantee the understanding of questions by adolescents aged between
12 and 15 years and the questionnaire adequacy to the adolescents' reality.

A total of ten
students completed the questionnaire inadequately and, as a result, were not
included in the analysis. Other eight questionnaires were excluded, because
respondents' ages were out of the usual 7th and 8th grade
students' age range (below 11 years or above 16 years). The final number of
questionnaires analyzed was 1,115. Losses were insignificant for the purposes
of the analyses.

Students were asked
about beer drinking throughout life, in the previous year and in the last 30
days, the latter providing the most reliable responses, because there were inconsistencies
in responses (for example, a student reported not having drunk beer in the previous
year, although mentioning having done so in the last 30 days). The response
variable was, therefore, beer drinking in the 30 days prior to the study (yes;
no).

The independent
variables were sex, age (> 14 years; < 14 years), school attended,
presence of a bathroom in the house (yes; no), importance of religion (very
important; no), having a favorite alcoholic beverage brand (yes; no), believing
that commercials tell the truth (true; false), considering parties one goes
to as similar to those seen in alcohol commercials (true; false); paying attention
to alcohol commercials (yes; no), previous tobacco use (yes; no), and whether
parents usually know where their children are, which was used to indicate parental
monitoring (yes; sometimes; never). "Having a bathroom in the house" was included,
because not having a bathroom in the house in current days is a strong indication
of poor housing conditions and, consequently, of economic status.

Age, importance
of religion and having a bathroom in the house were statistically different
among the three schools analyzed and researchers chose to maintain them as control
in the regression model. The remaining independent variables comprised the initial,
saturated or complete model whenever they showed a statistical significance
of at least 10% (p < 0.10) in the univariate analysis, i.e., when individually
compared with the response variable. Only those with a significance < 0.05
in the set of variables remained in the final model.

Possible multiplicative
interactions were tested, although not significant. The Hosmer-Lemeshow test
was performed to evaluate model adequacy. Analyses were made with the SPSS software,
version 15.0.

The present study
was approved by the Research Ethics Committee of the Universidade Federal de
São Paulo (Process 1767/05).

RESULTS

Sex distribution
was homogeneous among schools (53.3% of girls) (Table
1). Each school showed one characteristic that distinguished it from the
others, in terms of the presence of a bathroom in the house, importance of religion
and age. The socioeconomic variable that revealed the greatest difference between
schools was the presence of a bathroom in the house.

Sex and school
did not remain in the final model, because they were not statistically associated
with alcohol drinking in the previous 30 days in the presence of the remaining
variables (p > 0.05). All remaining independent variables were positively
associated with beer drinking in the 30 days prior to questionnaire application
(Table 2), even after control for age, importance
of religion and presence of a bathroom in the house.

"Parents who know
where their children are when they are not together" was an important protective
factor: not to know this corresponded to an odds ratio (OR) of 2.139 for beer
drinking in the previous month.

Variables directly
linked to advertisements were associated with beer drinking in the last 30 days.
The belief that alcohol commercials tell the truth showed an association with
alcohol drinking (OR = 2.122; p = 0.000), as did the perception of similarity
between commercials and students' real life, defined as "the parties I go to
are similar to those on commercials" (OR = 1.712; p = 0.009). Paying attention
to commercials showed a higher risk of alcohol drinking (OR = 1.563, p = 0.028),
although the strongest association was observed with having a favorite alcoholic
beverage brand (OR = 5.150; p = 0.000).

This is an original
study in Brazil that shows the association between alcohol advertisements and
beer drinking among primary school students, who have not reached the minimum
legal age of 18 years for drinking. This association occurs according to at
least four aspects: similarity perceived between advertisements and adolescents'
lives, attention paid to commercials, belief that commercials tell the truth
and having a favorite alcoholic beverage brand. This is observed even when controlling
for other aspects that are traditionally associated with alcohol drinking among
adolescents, such as age, sex, parental monitoring (protective factor), social
class, tobacco use and importance of religion5 in the adolescents'
lives. With regard to religiousness, a recent Brazilian study affirmed that
the fact of an individual being raised in a home where religion is not relevant
increases the chance of adopting the standard alcohol drinking habit.5

Results of the
present study are compatible with those of other studies that associate advertising
awareness and propensity to drink. Collins et al (2005) stated that attention
paid to commercials is the most relevant predictive factor of advertising awareness9
and of alcohol drinking in boys.8

The belief that
alcohol commercials tell the truth can be associated with adolescents' perception
of similarity between situations in their lives and those that appear in alcohol
commercials. If adolescents believe this, commercials can be seen as sources
to define their ideas about "normal drinking habits", which leads to the importance
of debating the content to which they are exposed.3 The ability to
distinguish what one sees in commercials and real situations can be developed
with alcohol use prevention programs, by educating adolescents about the media.
Loyalty to a particular brand (having a favorite alcoholic beverage brand) associated
with increased beer drinking contradicts the alcoholic beverage industry's allegation
that messages emphasizing this loyalty do not have an impact on consumption.6
Studies indicate that loyalty to a brand per se indicates consumption,
including on larger scales.6,15 This loyalty, according to the alcoholic
beverage industry, the goal of its advertisements, can be the result of excessive
exposure to this media.

Certain attitudes
can be taken to reduce the influence of beer advertisements on adolescent consumption.
One of them, part of a theory developed by Conar, is to control the content
of advertisements, which must be limited to the adult universe and should not
enable one to perceive the similarity between advertisements and real life situations
of the majority of adolescents. Adolescents' perceptions of the similarity between
beer advertisements and their lives, found in the present study, suggest that
self-regulatory rules are not efficient to protect the most vulnerable population
in Brazil. Violation of self-regulatory marketing codes for alcohol advertisements
was also detected in Australian, American and Italian studies.2,7,12,23,26,e

Studies suggest
that the most efficient way to control the influence of advertisements on alcohol
drinking would be the reduction of exposure of those who are younger, restricting
the number of alcohol advertisements, including beer, on television and other
means of communication.27 Currently, there are no restrictions to
beer advertisements in Brazil.

While legal measures
are not taken in this sense, society can reduce this influence by focusing on
those who receive the messages (adolescents) and educating them about the media.f
Advertisements would stop being a reference point for what is "normal" or "real"
and would begin to be seen by adolescents as tools used to influence them towards
the consumption of alcoholic beverages, foods and clothes, among others.

Education about
the media aims to understand the way advertisements shape adolescents' view
of their environment. The objective is to make those who receive messages -
the adolescents - develop a detached and critical view, which enables them to
make judgments and make their own decisions.f
Education about the media has been studied with other health issues, such as
eating habits and sexual behavior.11,14 Activities provided by schools
and aimed at these questions could open space for debate and guidance.

Limitations to
this study include: the fact that the sample comes from one city exclusively,
the impossibility of measuring the actual strength of association and the cross-sectional
nature of the investigation, whose methodology does not allow for the establishment
of a relation of causality, although it points out the directions to be followed
by future studies. The results of the present study indicate ways through which
advertisements can influence adolescents' consumption and what can be done to
prevent this, once they are consistent with previous studies and the association
is plausible.22

The responsibility
for the development, codification and internalization of the messages transmitted
by the media falls on both the one who sends the message and the other who receives
it. Certainly, the media is not the direct cause of alcohol drinking. However,
there is an association between the messages conveyed by the media and adolescents'
behavior. Part of the so-called "social responsibility" of advertisement in
general and of the alcohol industry in particular, which cannot be neglected,
resides in this conversion from idea to social practice.